Nokea
The nurse is caring for clients on an orthopedic floor. Which client should be assessed first?
- A. The client diagnosed with back pain who is complaining of a '4' on a 1-to-10 scale.
- B. The client who has undergone a myelogram who is complaining of a slight headache.
- C. The client two (2) days post-disk fusion who has T 100.4, P 96, R 24, and BP 138/78.
- D. The client diagnosed with back pain who is being discharged and whose ride is here.
Correct Answer: C
Rationale: Fever, tachycardia, and tachypnea post-disk fusion suggest infection or complications, requiring urgent assessment. Mild pain, headache, and discharge are lower priority.
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What is the goal of therapy for a child newly diagnosed with scoliosis as explained by the nurse?
- A. Limit or stop progression of the curvature of the spine.
- B. Prepare the child for surgical correction at a later date.
- C. Minimize the complications of prolonged immobilization.
- D. Develop a pain management plan to minimize complications.
Correct Answer: A
Rationale: The primary goal of scoliosis treatment is to halt or limit the progression of spinal curvature.
The client diagnosed with osteomyelitis of the left foot and ankle is being prepared for a below-the-knee amputation. Which intervention to improve the client’s functional ability is a priority after rehabilitation?
- A. Keep a large tourniquet at the bedside to stop potential bleeding from the amputation site.
- B. Place a pillow in the bed for the client to push the stump against many times per day.
- C. Take and document the client’s vital signs every four (4) hours.
- D. Have the dietary department send high protein, high-carbohydrate meals six (6) times a day.
Correct Answer: B
Rationale: Pushing the stump against a pillow toughens the residual limb, improving prosthesis use and function post-amputation. Tourniquets are for emergencies, vitals are routine, and frequent meals are excessive.
A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery?
- A. Place the right thumb directly on ice.
- B. Put the right thumb in a glass of warm water.
- C. Wrap the thumb in a clean piece of material.
- D. Secure the thumb in a plastic bag and place on ice.
Correct Answer: D
Rationale: Wrapping the thumb and placing it in a bag on ice preserves viability for reattachment without freezing tissue. Direct ice causes frostbite, warm water promotes decay, and wrapping alone is insufficient.
The client is a 64-year-old male admitted to the hospital with severe pain in his right big toe, which is red and swollen. Which nursing care measure is most essential for the nurse to perform at this time?
- A. Use a bed cradle on the bed
- B. Put a bed board on the bed
- C. Obtain a heat lamp
- D. Prepare to catheterize the client
Correct Answer: A
Rationale: A bed cradle keeps bedding off the painful, swollen toe in gout, reducing discomfort.
The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a nonmodifiable risk factor?
- A. Calcium deficiency.
- B. Tobacco use.
- C. Female gender.
- D. High alcohol intake.
Correct Answer: C
Rationale: Female gender is a nonmodifiable risk factor for osteoporosis due to lower bone density post-menopause. Calcium deficiency, tobacco, and alcohol are modifiable.